Insurance and DME

[ThisGuy]

I'm just getting started. I have an appointment with my DME next week. They told me they have me approved with my insurance and have my Rx for auto cpap. They explained that my insurance required a payment plan of $350 initial payment and then 10 payments at $45. Payment would drop to $9 (20%) after my deductible is met. From reading this forum, I get the idea that I should follow up with my insurance company to verify. So far what the DME explained seems logical based on what I've seen. I called Anthem to confirm. The lady is completely confused. She doesn't know anything about monthly payments or compliance and keeps insisting that once I meet my deductible they will pay 80%. I try to explain to her the payment \ rent \ compliance situation that is required by insurance and she just keep referring to my deductible. So, I asked if I buy whatever equipment I want and it's $1000, there is no rent and Anthem will pay 80% after my deductible and she said yes. I'm 100% certain it doesn't work this way. Do I just hope that my DME is giving me the correct info or what. Obviously Anthem doesn't know what is going on. Having no experience with cpap, I think using a DME would be helpful in picking the equipment and working with my insurance, but I want to know what I am in for. Would it be easier to just buy online or used and then use a DME for masks and supplies? How do I know my insurance will cover the purchase if I do buy online?

[LAGrandpa]

Call your insurance and ask them if they will reimburse you if you buy your machine online. That's the only way you can know.

[BlackSpinner]

I would call again and hopefully get another person. If they say the same thing, ask for it in writing. Make sure to get their name and id reference. If your insurance is through work check with HR and the person incharge of insurance. Get the information faxed to them.

If the DME says it is midnight and raining, always check out side.

[chunkyfrog]

Call your insurance, and ask for a list of DME's in network, and an explanation of your cpap benefits
(especially allowable amounts per HCPCS code)---IN WRITING.
Also ask if there is any coverage for out of network suppliers. (Online, etc.)

[Jay Aitchsee]

Well, it could be, but...

Your Insurance company, not the DME decides what they will pay to those "in network". I doubt the DME has you "approved", but they indeed may know what your insurance company will pay. If they are in network, no doubt there is standardized pricing in place and the DME should know what it is. In network means your insurance company has authorized you to use the provider and they have an agreement with the provider to allow a set dollar amount for specific products and services. Insurers may or may not require a rental period.

Since they have you approved, ask them for the name and number of your insurance company representative that "approved" you. Or, have them show you the approval from the insurance company. Then contact the insurance company. The insurance company is paying the bills.

Get a copy of the order (Rx) from you doctor. In case you want to purchase on your own.

Know that not all auto (desirable) machines are data capable (essential). Find out the exact name and model that will be furnished. Auto cpap is not enough.

Our host, CPAP.com, has a new Airsense 10 autoset for $833, not much more than you would pay if your detuctible wasn't met and it could probably be gotten cheaper.

Bottom line, you need to know from your insurance company the coverage they provide you.

[Cardsfan]

Are you 100% sure this DME is In Network with your insurance? Verify everything with your insurance Co- get it in writing- before you commit to anything. Not everyone has to rent and prove compliance, I did not. I just had to meet my deductible of $500, then pay my 20% copay after that. Do not trust the DME to know your insurance rules.

[Cardsfan]

Be very aware that "being approved by your insurance" and being "In Nework" are not the same thing. Make SURE your DME is In Network with your insurance to get your full benefits.

[amenite]

If you really want to know the deal get your copy of the plan benefit document for your health care plan and locate the sections dealing with Durable Medical Equipment and xPAP therapy if it's mentioned specifically. That document is what will take precedence despite what the DME or any representative from the insurer says over the phone. Whether you get that far or not, do as others have suggested and ensure the DME is in network for you and you are covered for what you expect you're covered for. Assume that the DME out to extract every penny they can get from you and your insurer until they prove otherwise, and never give them a credit card number or SSN or even a DL number. Insist they bill you by mail and fire them the second time they complain about it.

And get a copy of your prescription. It's your right to have it and your doctor's responsibility to provide it. That way you have the power to do what you choose.

[Janknitz]

NEVER, NEVER, NEVER, EVER, EVER, EVER Trust what a DME tells you. NEVER!

It sounds like the people on the other end of your insurance company's phone line are clueless as well.

What I recommend in this case is that you get a copy of the "Evidence of Coverage" ("EOC"). The EOC is the contract between you and your insurer that you have NEVER seen (unless you knew enough to specifically ask for it). The EOC should spell out how DME is covered--whether they require rental or purchase, and if rental for how long. There should also be specific policies for coverage with in-network DME providers and non-network providers.

State law governs the time limits for furnishing you with an EOC on written request--usually 7 to 10 days. Some insurers now have them online if you have a secure portal website to access your insurance information. Since they are considered "proprietary" (AND they don't want you to see limitations before contracting with them for the insurance) they are rarely publicly accessible.

Then you need to confirm with your insurer whether this specific DME is considered in-network on your plan. Ideally you can find this somewhere in writing--a website or a list furnished by the insurance company (but this may or may not be up to date). When you talk to the insurer, be sure to get the name of the person you speak to, mark down the date and time, and keep a record. All of these insurers now record such conversations and CAN (and do) go back to review the tapes if there's a dispute.

[Born2Bwild]

I went thru the same thing
DME that was my prescription sent to without my knowledge told me that rent to purchase is mandatory by insurance to show compliance to pay. However, when I called insurance they told me there is no such thing and they will pay 80% of the cost of in network DME and 70%of out of network. After I did the math it cost just little over 200 for my equipments. You're getting good advice by never trust what DME tells you.
In my case I end up stumbling on a honest DME who cared less about rent to purchase and offered me outright purchase from the start.so now no compliance, no one monitoring me no nothing and all of the equipment are MINE. a great feeling.
Good luck hope it helps

[LSAT]

I went thru the same thing
DME that was my prescription sent to without my knowledge told me that rent to purchase is mandatory by insurance to show compliance to pay. However, when I called insurance they told me there is no such thing and they will pay 80% of the cost of in network DME and 70%of out of network. After I did the math it cost just little over 200 for my equipments. You're getting good advice by never trust what DME tells you.
In my case I end up stumbling on a honest DME who cared less about rent to purchase and offered me outright purchase from the start.so now no compliance, no one monitoring me no nothing and all of the equipment are MINE. a great feeling.
Good luck hope it helps

I would be careful here......Most insurance requires compliance. You may get a call from the DME asking you to send in your SD card so they can see if you have used the machine for the required time...usually at least 4 hours a night for 70% of the nights. If not...they can ask for the machine back.

[Born2Bwild]

Not my insurance. They already paid for it, your are right MOST insurance but not mine, as long as there was a prescription the insurance cared less about compliance. To my knowledge, the only time compliance become an issue is when you are going thru an employer and DOT card but then again I could be wrong.
And don't get me wrong I I, in it to use it and I do use it almost consistently, I just don't like being lied to or monitored by DME if I don't have to.

[ThisGuy]

I'll try again to see if another representative can make more sense of my coverage. I did get a copy of the benefits and it's just as vague, but does give me 80% coverage in and out of network. The DEM statement does mention paying the rental charge, but doesn't explain anything. I was also able to log into my online account and sent a message asking for specific details on coverage and rental.

Medical Supplies and Equipment In Network Out of Network
 Medical Supplies 80% 80%
 Durable Medical Equipment 80% 80%
 Orthotics- Foot and Shoe Based on Medical Necessity 80% 60%
 Prosthetic Appliances (external) 80% 60%


Durable Medical Equipment
This Plan will pay the rental charge up to the purchase price of the equipment. In addition to meeting
criteria for Medical Necessity, and applicable Precertification requirements, the equipment must also be
used to improve the functions of a malformed part of the body or to prevent or slow further decline of the
Member’s medical condition. The equipment must be ordered and/or prescribed by a Physician and be
appropriate for in-home use.

[Cardsfan]

Clear to me.

Durable Medical Equipment is paid at 80% , In network and out of network. The person at your insurance co. was correct. Meet your deductible, then they pay 80 %. You do not HAVE to rent and do not have to show compliance.

The rental equipment clause is for short term use items that you plan to return to the DME. (such as a wheelchair or crutches when you break a leg)

Again- do NOT ever trust the DME to tell you what your insurance covers. Your DME does not want you to know you can buy it somewhere else without having to rent from them. $$$$$$$

Get everything in writing and confirm with your insurance co.

[Janknitz]

And you can choose any DME you want. So if this DME is playing games, find a better one.